Quality of Life at End of Life vs. Aggressive Care

[CaroleHammett]

Aggressiveness of Care in a Prospective Cohort of Patients With Advanced NSCLC. Cancer. 2008 Aug 15;113(4):826-833, JS Temel, J McCannon, JA Greer, VA Jackson, P Ostler, WF Pirl, TJ Lynch, JA Billings

Quality of life is becoming a measure of quality of cancer care, and the measure includes not only length of life but also quality at the end of life. While various studies have identified factors considered priorities for enhancing end-of-life quality, whether this knowledge has translated into action is unknown. In fact, it has been noted that patients with advanced cancer are often treated more aggressively at the end of life. In this study, the aggressiveness of care at the end of life was assessed prospectively in a cohort of patients newly diagnosed with advanced non-small-cell lung cancer (NSCLC), an incurable disease with a poor long-term prognosis.

The analysis was based on data from a subset of 46 patients who were enrolled between December 2003 and June 2005 in a palliative care study conducted at Massachusetts General Hospital. All of the patients had been diagnosed within the preceding 8 weeks with advanced-stage NSCLC and had an Eastern Cooperative Oncology Group performance status of 0 to 1.

The patients received both standard anticancer therapy and integrated palliative care. The latter included monthly outpatient meetings with the palliative care team and daily meetings when the patients were hospitalized. The oncologists caring for these patients were aware of the palliative care study, but they were not aware of the aggressiveness-of-care subanalysis. At the time when the subset data were analyzed, 40 patients had died; thus, the subanalysis was based on data from these patients.

One quarter of the patients received radiation therapy before systemic therapy; all 40 patients underwent systemic therapy. Due to adverse effects or lack of response, second-, third-, and fourth-line or greater therapy was undertaken in 60%, 38%, and 18% of the patients, respectively. Response rates to the latter 2 types of therapy are only 10%. Response rates to second-line therapy are 40% to 60%, although the median progression-free survival is only about 2 months.

Anticancer therapy was given to 40% of the patients (n = 16) within 30 days of death; of these patients, 5 began a new regimen. Nine patients (23%) received anticancer treatment within 14 days of their death; none of these patients were also receiving hospice care. Enrollment in hospice was high (65%), but in the last month of life, 48% of patients made visits to the emergency department, and 50% were admitted (average length of stay, 4.05 inpatient days [standard deviation = 5.34 days]).

Most patients (62%) died as hospice patients, either at home or in hospice facilities; 25% were in the hospital at the time of death. Median length of hospice stay was 16 days; 31% of patients received hospice care for less than 1 week.

Exploratory bivariate analysis showed that aggressive treatment within 2 weeks of death was more likely to be given to patients who were anxious (67% vs 21%; P = 0.05, 2-sided Fisher exact test) or depressed (50% vs 11%; P = 0.05, 2-sided Fisher exact test). No other characteristics were associated with the use of aggressive measures at the end of life.

The study authors note that oncologists give anticancer therapy to provide symptomatic relief and palliation, as well as in the hope of improving survival. Pain, cough, and fatigue are improved to a greater extent with chemotherapy than with optimal supportive care. The availability of novel oral agents (eg, epidermal growth factor tyrosine kinase inhibitors) that are less toxic and more easily administered than infusions makes it easier to continue anticancer therapy at the end of life.

However, continuing anticancer care until the end of life usually precludes hospice care, since most hospice programs will not accept patients receiving such treatment. Hospice care provides vitally important palliative and psychosocial support for patients and their families. Given that 40% of patients in this study were receiving anticancer therapy within 30 days of death, it is likely that end-of-life care may not have been optimal for many of these patients, as evidenced by the late referrals to hospice and the short lengths of stay. One solution might be to revise hospice enrollment requirements (eg, to allow open-access hospice) so that patients and their families can receive the needed support. Considering the association between anxiety and the receipt of aggressive treatment at the end of life, there is reason to believe that alleviating patients’ anxiety may improve end-of-life outcomes.

This summary was written by the OncologySTAT editorial team

ElsevierCopyright © 2008

Source: http://www.oncologystat.com/journals/jo ... 9DE4BA617D

There have been extensive discussions in other forums on our message boards regarding the problem of patients not being admitted to hospice until the last minute (reducing their Quality of Life at the end of their lives). One explanation for this, included above, but not mentioned in these earlier postings, is that patients who are receiving chemo or radiation for the purpose of slowing or stopping progression (as versus for "comfort care") are ineligible for hospice.

See also recent earlier Quality of Life article and discussions at http://www.lungevity.org/l_community/vi ... hp?t=38290

Carole

I'd rather die while I'm living then live while I'm dead.--Jimmy Buffett